What Is Annular Tear?
The intervertebral discs are enclosed by a tough outer covering known as Annulus Fibrosus. Tearing or ripping of annulus fibrosus is known as Annular Tear.(1) The intervertebral discs act as cushions between the vertebrae and their function is to act like shock absorbers and also to give support to the bone structure of the neck and back. Excessive strain/ stress on the discs occurring from repetitive activities, such as sitting, standing etc. or trauma/injury, which also puts strain on the discs causes annular tear; or such types of exertive pressure or stress results in an annular tear. Annular tears can cause a lot of pain in the patient and can be quite debilitating and hampering to a patient’s quality of life. So, it is important to seek proper treatment, as soon as the patient experiences symptoms of annular tear.
Some cases of annular tear heal on their own with conservative methods like pain medications, ice/heat therapy, massage, physical therapy etc. If the patient does not benefit from conservative approach and continues to feel pain or if the annular tear has progressed to disc herniation, then surgery is required.
Types Of Annular Tear:
Annulus fibrosus is composed of different layers. The type of tear is categorized on the layer which is torn and the nature of the tear. Following are the different annular tears:
- Radial Tears: This type of annular tear occurs as a result of natural aging process. Radial tears start from the middle of the disc and continue all the way to the outer layer of the annulus fibrosus. Radial tears can also result in disc herniation.
- Peripheral Tears: This type of annular tear occurs in the external fibers of the annulus fibrosus. The cause of peripheral tears is often a traumatic injury. Peripheral tears can also cause breakdown or degeneration of an intervertebral disc.
- Concentric Tears: Concentric tears commonly occur as a result of injury and they occur circumferentially between the layers of the annulus fibrosus.
Causes Of Annular Tear:
The most common cause of annular tears is the natural aging process of human beings. As the neck and back bear the brunt of the majority of the body’s weight, they are more prone to wear and tear or degeneration as time goes on. Many individuals have some amount of degeneration in the intervertebral discs by the time they have reached age 30. This degenerative process causes weakening of the annulus fibrosus, which makes them more prone to annular tears.
Other cause for tear is any traumatic injury, such as seen in individuals involved in high-impact sports like football, rugby, basket ball etc. Individuals whose occupations involve strenuous activities, such as heavy lifting or bending throughout the day are also more susceptible to annular tears.
Signs & Symptoms Of Annular Tear:
Patient experiences symptoms of annular tear when the annulus fibrosus is torn. The outer layer of the annulus fibrosus is highly innervated, which causes a lot of pain to the patient. Radial tears result in spilling or protrusion of the nucleus pulposus out to the surrounding tissue. This painful condition is known as disc herniation. In some cases, patient does not experience any symptoms at all, which leaves his spinal condition undiagnosed. Symptoms commonly experienced by a patient are:
- Severe pain.
- Patient is unable to perform daily activities of living due to pain.
- Patient experiences weakness in the arms and/or legs.
- Patient also experiences numbness and tingling sensations.
Investigations For Annular Tear:
- Physical examination.
- CT discography(2)
Treatment Of Annular Tear:
- If the tear is mild, then it often heals on its own. Conservative treatment is often sufficient for healing of most of the tears. However, if patient experiences severe pain and does not benefit from conservative measures, then surgery may be needed for relief.
- The goal of conservative treatment is to provide relief from symptoms and to decrease the chances of disc herniation.
- Almost all the uncomplicated annular tears heal on their own with conservative treatment over a period of months to weeks.
- Majority of the cervical annular tears heal on their own without any treatment.
- If patient has disc herniation along with the tear, then symptomatic treatment is done.
- Conservative treatment includes pain medications or NSAIDs like ibuprofen, naproxen, physical therapy. Ice/heat therapy also helps in alleviating pain.
- If patient has annular tear without the disc herniation, then surgery is rarely required and patient can benefit from conservative approaches mentioned above.
- An annular tear can also progress to a disc herniation where the nucleus pulposus, which is the inner gelatinous material, protrudes through the outer tear into the spinal canal. This protrusion can put pressure on the adjacent spinal nerves/ spinal cord resulting in pain. The body also treats this protruded nuclear material as abnormal and releases chemicals to breakdown this material for resorption and closure of the disc tear/fissure. If there is disc resorption, then surgery is not required.
- In some cases, the annular tears are completely asymptomatic. This happens if the tear is very narrow and there is no protrusion or leakage of nuclear material as there will be no painful compression of the nerves. Because of this, the patient will not experience any symptoms.
Healing Time For Annular Tear:
Healing time for annular tear varies from patient to patient. When there is an annular tear, the torn or extruded intervertebral disc material undergoes a chemical breakdown before being resorbed by the body. The process of chemical breakdown can vary from several weeks to a year. The symptoms of the patient can be easily managed while the healing takes place. The physician will design a treatment plan accordingly, which can include: Pain medicines, NSAIDs, cold/hot therapy, rest, massage and low-impact exercises. All these treatment methods will help with the blood circulation while the disc heals.
Exercises For Annular Tear:
It is important to rest for healing of the annular tear; however, it is also important to be a little bit active too. If the patient is completely sedentary or confined to bed, then it can result in joint stiffness, weakened muscles and decreased immunity. All of these things can have a detrimental effect on the disc resorption. So, it is important to do some low impact exercises under the guidance of your physician, such as:
- Other types of hydrotherapy.
- Therapy ball can be used to strengthen the core muscles.
- Exercising on an elliptical trainer.
- Patient can also use a recumbent stationary bike for exercising the muscles of the legs.